Wherein we ponder vexing issues in infection prevention and control, inside and outside the hospital.

Monday, May 7, 2012

Dawn of the age of untreatable infections? NDM-1 in India

"There is a tsunami that’s going to happen in the next year or two when antibiotic resistance explodes" - Abdul Ghafur, an infectious diseases physician in Chennai

Jason Gale and Adi Narayan have a feature article in this June's Bloomberg Markets discussing the rise of NDM-1 in India. It's well researched and organized and does a nice job highlighting the human tragedy that's in our midst. There are quotes from Bob Moellering, Donald Low, Tim Walsh, Lindsay Grayson, David Livermore, Keith Klugman, and several clinicians and scientists in India that have been directly involved in NDM-1 discovery and treatment including Chennai microbiologist Karthikeyan Kumarasamy, who helped discover NDM-1. Overall, this is a great resource for the intro to any NDM-1 or Gram-negative resistance talk.

I agree with CDC's Tom Frieden when he says that "we need to have good surveillance and ... we need to have good antibiotic stewardship," but I think we really need more than that. The article finishes with a quote by David Livermore who says "“Combine sophisticated medicine,
poor sanitation and heavy antibiotic
usage, and you have a rocket fuel to
drive the accumulation of resistance...That surely is what
India has created.”

Sure NDM-1 is in India but the problem of Gram-negative resistance is a much larger, non-border controlled, issue. Wasn't KPC first detected in North Carolina? If we point (and then focus on) fingers, we miss the larger picture - Bruce Lee's Enter the Dragon? We need large investments in antibacterial discovery and infection prevention research and we need to build back up our public health infrastructure in the US. We're in this together.

Addendum: I was concerned that Gale's well-written article would be used to point fingers and not pressure people to find solutions. It seems that the first tweets from Bloomberg Markets are playing on fear and trying to scare people away from medical tourism in India. It's too bad that articles like this can't be used to make a case for a coordinated response to the MDR-bacterial threat we face. I hope further discussion of this article takes a more long-term view.

Addendum #2: Now this editorial by the Bloomberg Editors is more like it. Although they still seem to miss that emergence is not limited to places like India with poor sanitation. KPC emerged in the US and MDR-Acinetobacter is alive and well on the East Coast. If you haven't read it, Andrew Moore's 2003 story of the FDA's failure to approve magainin, is an amazing look into the barriers to antibacterial discovery.

Addendum #3: Listen to author Jason Gale discuss India's special place in the emergence of antibacterial resistance on PRI's The World. He says that "when you look at the drivers of drug resistance, India pretty much ticks every single box"